Transcript Ulcer - Montana Performance Improvement Network

Integumentary System
Diagnostic Coding
©Irene Mueller, EdD, RHIA
Montana Hospital Association
July 18, 2012
http://etc.usf.edu/clipart
Skin Diagnostic Coding
• ICD-9-CM
– Chapter 2 Neoplasms
– Chapter 15 Diseases of Skin and SQ Tissue
– Chapter 17 Injury and Poisoning
• ICD-10-CM
– Chapter 2 (C00-D49) – Neoplasms
– Chapter 12 (L00-L99) – Diseases of Skin & SubQ
– Chapter 19 (S00-T88) – Injury, Poisoning, & Other
consequences of External Causes
• Similarities / Differences
Similarity
• Coding Steps remain the same
– Identify all main terms in diagnostic statements
• Apply your knowledge of A& P and pathology,
pharmaceuticals, and treatments
• Main terms are USUALLY Nouns
– Identify modifiers in diagnostic statement
• Modifiers are USUALLY adjectives
– Locate main terms in AI
• If terms not identical, use your medical terminology
knowledge to translate from documentation to code
book
Coding Steps
– Locate modifiers in subterms under main terms
– Check for special instructions or cross-references
– TENTATIVELY select a code
– Turn to code category in TL
– Check for any instructional notes for code
category/chapter
– Apply your knowledge of code book conventions
– Assign code when all elements of dx statement
accounted for and code verified in TL
Similarities
• ICD-10-CM = Same hierarchical structure
– 1st three characters are category of code
– All codes within same category have similar traits
• Alphabetic Index to Diseases and Injuries
– Same format and use as ICD-9-CM AI
– Table of Drugs and Chemicals
– Neoplasm Table
• Index to External Causes
Differences
• ICD-10-CM Codes
– Higher specificity
• Laterality
• Add’l characters for more details
• Other changes
– More combination codes
• Etiology and Manifestation
• Poisoning and external cause
• Diagnosis and symptoms
Differences
• Code titles & language that reflect accepted
clinical practice
• Codes able to reveal more about quality of
care, so data can be used in more meaningful
ways to better
– Understand complications
– Design clinically robust algorithms
– Track outcomes of care
– Information for clinical decision making and
outcome research
Differences
• ICD-10-CM consists of 21 chapters
compared to 17 chapters in ICD-9-CM
• ICD-9-CM’s V and E codes incorporated into
main classification in ICD-10-CM
• Reflecting current medical knowledge,
certain diseases reclassified (reassigned) to
more appropriate chapter in ICD-10-CM
• Injuries classified by site and THEN type
Improved Excludes notes
• Excludes1 = NOT coded here
– Excluded code is NEVER used with code
– Two conditions cannot occur together
• Excludes2 = NOT INCLUDED here
– Excluded condition is NOT part of condition
represented by code
– Acceptable to use both codes together IF
patient has both conditions
Excludes Notes Examples
L 24 Irritant contact dermatitis
• Excludes1:
• Excludes2:
– allergic contact dermatitis L23.– allergy NOS T78.40
– contact dermatitis NOS – dermatitis due to substances
taken internally L27.L25.9
– dermatitis NOS L30.9 – dermatitis of eyelid H01.1– diaper dermatitis L22
– eczema of external ear H60.5– perioral dermatitis L71.0
– radiation-related disorders of
skin and subcutaneous tissue
L55-L59
Neoplasm Chapters
• Most chapter-specific guidelines same, except
• I.C.2.c.1, Anemia associated with malignancy
• I.C.2.c.2 Anemia associated with
chemotherapy, immunotherapy and radiation
therapy
ICD-10- CM I.C.2.c.1,
Anemia associated with malignancy
• When admission/encounter is for
management of an anemia associated
with the malignancy, and the treatment is
only for anemia, the appropriate code for
the malignancy is sequenced as the
principal or first-listed diagnosis followed
by the appropriate code for the anemia
(such as code D63.0, Anemia in neoplastic
disease)
• Reverse of ICD-9-CM
ICD-10-CM I.C.2.c.2
• Anemia associated with chemotherapy,
immunotherapy and radiation therapy
• When admission/encounter is for mgt of an
anemia associated with adverse effect of
administration of chemotherapy or
immunotherapy and the only treatment is for
the anemia, the anemia code is sequenced
first followed by appropriate codes for
neoplasm & adverse effect (T45.1X5)
• Same sequencing as ICD-9-CM
ICD-10-CM I.C.2.c.2
• When admission/encounter is for mgt of
anemia associated with adverse effect of
radiotherapy, anemia code should be
sequenced first, followed by appropriate
neoplasm code and code Y84.2, Radiological
procedure and radiotherapy as cause of
abnormal reaction of patient, or of later
complication, without mention of
misadventure at time of procedure.
ICD-9-CM 2012
• 173 - Other and unspecified malignant
neoplasm of skin
– All subcategories were expanded to fifth-digit
level to classify
• Basal cell carcinoma
• Squamous cell carcinoma
• Other specified and unspecified malignant neoplasms
• New codes added
– Pilar cyst (704.41)
– Trichilemmal cyst (704.42)
• Outer root sheath of hair
Neoplasm Example 1
• This 25-year-old female is
treated for melanoma of the
left breast and left arm
Example 1 ICD-9-CM Answer
• Melanoma, breast
– Malignant melanoma of skin – 172
– Includes melanoma (skin) NOS
• Trunk, except scrotum – 172.5
– Includes breast
• Melanoma, forearm
– Malignant melanoma of skin – 172
– Upper limb, including shoulder – 172.6
• 172.5
• 172.6
Example 1 ICD-10-CM Answer
• C43.52 Melanoma (malignant), skin,
breast (female) (male)
• C43.62 Melanoma (malignant), skin, arm
Example 1
ICD-10-CM Explanation
• To code Melanoma, code is found directly
in Index rather than Neoplasm Table
• NOT correct to assign primary site of skin
(C44.52, C44.62) when melanoma
documented
• Melanoma in situ = category D03.1
Neoplasm Example 2
• 50-y-o female diagnosed w/ left breast
carcinoma four years ago, when she had left
mastectomy performed w/ chemotherapy. She
has been well since then w/ no further tx
except for yearly checkups. Pt is now being
seen w/visual disturbances, dizziness,
headaches, and blurred vision.
• Workup revealed metastasis to brain,
accounting for symptoms. Identified as
metastatic from breast, not new primary.
Example 2 ICD-9-CM Answer
• Carcinoma, metastatic – See Metastastis, cancer
– to specified site (M8000/6) See Neoplasm, by site,
secondary
– Neoplasm, brain NEC - 198.3
• History, malignancy (personal), breast
– Personal history of malignant neoplasm, breast – V10.3
• Absence, acquired, breast
– V45.71
• History, Chemotherapy, antineoplastic disease
– V67.41
Example 2 ICD-10-CM Answer
• C79.31 Refer to Neoplasm Table, by site,
brain, malignant, secondary site
• Z85.3 History, personal (of), malignant
neoplasm (of), breast
• Z90.12 Absence (of) (organ or part)
(complete or partial), breast(s) (and
nipple(s)) (acquired)
• Z92.21 History, personal (of), chemotherapy
for neoplastic condition
Example 2 ICD-10-CM
Explanation
• Encounter for metastatic brain ca
• Previously excised primary ca w/ no further tx:
therefore, coded hx of breast cancer
• Previous mastectomy, so code for acquired
absence of breast. Laterality can be specified in
Z90.1 subcategory
• Documented brain metastasis caused
symptoms, so not coded
• Code available for hx chemotherapy IF facility
codes to that level of detail
ICD-10-CM Skin Chapter
• Nearly all categories & subcategories
expanded to either fourth- or fifth-character
level
• More codes with following directives
– Use additional code (B95–B97) to id organism
– Code 1st (T36–T65) to identify drug or
substance
– Code 1st underlying disease
– Code 1st any associated . . .
Coding Guidelines
• For Skin chapter in both ICD-9 and ICD-10
– Only Pressure ulcers
– Several identical
– Some different for ICD-10-CM
• Due to more specific codes available
• Therefore, coder will apply general coding
guidelines and codebook conventions
when coding other skin conditions
Non-Pressure Ulcers
• Generally, underlying condition responsible
for non-decubitus ulcer of lower limb (L97)
• When underlying condition documented, use
Combination code
• L97 can be PrDx, when underlying condition
NOT documented
Non-Pressure Ulcers in
ICD-10-CM (L97)
• Non-pressure chronic ulcers of lower limb
– Chronic ulcer of skin (NOS)
– Non-healing ulcer of skin
– Non-infected sinus of skin
– Trophic ulcer NOS
– Tropical ulcer NOS
– Ulcer of skin NOS
• Can be Pr Dx IF no underlying condition
Non-Pressure Ulcers
in ICD-10-CM
• Assume causal condition any condition
below with LE ulcer
– Atherosclerosis of LE
– Chronic venous hypertension
– Diabetic ulcers
– Postphlebitic syndrome
– Postthrombotic syndrome
– Varicose ulcer
– Any associated gangrene
Non-Pressure Ulcer Example
Pt tx in outpatient hospital wound care clinic for
severe non-healing ulcer of L midfoot and heel
w/ bone necrosis due to diabetes mellitus
ICD-9-CM
ICD-10-CM
250.81 Diabetes with other
specified manifestations,
type I
[juvenile type], not
stated as uncontrolled
E11.621 Diabetes mellitus due
to underlying condition
with foot ulcer
707.14 Ulcer of heel and
midfoot
L97.423 Non-pressure
chronic ulcer of
Left heel and midfoot
with necrosis
of bone
Pressure Ulcers in ICD-9-CM
• Need two codes
– One for ulcer
– One for stage
• Gangrene IF present is add’l code
• Multiple ulcers of same site
– Only assign code for most severe ulcer
Pressure Ulcers
in ICD-10-CM (L89)
• Similarities to ICD-9-CM • Differences
–
–
–
–
Stage I-IV
Un-stageable
Unspecified
Need to know location
– ONLY one code in ICD10-CM –ulcer & stage
– 4th character = anatomy
details
• Right vs Left
• Upper vs Lower
– 5th character = specific
site
– 6th character = ulcer
depth (Stage)
– Gangrene IF present is
sequenced FIRST
Pressure Ulcers ICD-10-CM (L89)
• Stages I –IV
• Un-stageable
– Reasons pressure ulcers unstageable
• Can’t examine
– Under dressing/Not debrided
– Covered by eschar/blister
– Best practice - Let healing occur until skin breaks
down
• Ulcer is evolving
– Eventual extent of injury unclear until tissue
demarcates
• Unspecified
Pressure Ulcer Examples
• Dr called by Nursing Home to treat Pt with
bed sores on R buttock
• Dr documents
– Decubitus ulcer, R buttock, stage II
ICD-9-CM
ICD-10-CM
707.02 Decubitus ulcer
L89.312 Pressure ulcer of
of the buttock
707.22 Pressure ulcer
stage II
right buttock stage II
Pressure Ulcer Examples
• Pt with gangrenous pressure ulcer of Left
ankle, with necrosis of muscle & bone
ICD-9-CM
707.06 Pressure ulcer, ankle
ICD-10-CM
I96 Gangrene, NEC
707.24 Pressure ulcer, stage IV L89.524 Pressure ulcer
Left ankle, stage IV
785.4 Gangrene
Skin Example 1
• Dermatitis covering entire body due to
antibiotics (penicillin) taken correctly as
prescribed.
Skin Example 1 ICD-9-CM
Answer
• Dermatitis
– Due to
• Drugs taken internally - 693.0
• Use add’l code to id drug –
– E930.0 (Therapeutic Use)
• 693.0
• E930.0
Example 1 ICD-10-CM
ANSWER
• L27.0 Dermatitis (eczematous), due to, drugs
and medicaments (generalized) (internal
use)
• T36.0X5A Table of Drugs and Chemicals,
Penicillin (any), Adverse Effect, initial
encounter
Skin Example 1 Explanation
• Reason for encounter - extensive dermatitis adverse effect of penicillin
• Instructional note in Tabular under code L27.0
– Use additional code for adverse effect, if
applicable, to identify drug
– Following note, T36.0X5A sequenced as 2ndary
DX
– Seventh character of T36.0X5A
• Initial encounter (A) for this condition
Skin Example 2
• Pt seen for IV antibiotic treatment of
cellulitis of R anterior neck. Pt also
known morphine drug abuser &
exhibited considerable drug-seeking
behavior; continuously requested
morphine. All narcotics discontinued
& pt exhibited no drug withdrawal
symptoms.
• Diagnoses: Cellulitis, right anterior
neck; morphine drug abuse
Example 2 ICD-9-CM Answer
• Cellulitis
– Neck – 682.1
• Use additional code to identify organism (note at 682)
• Abuse, drugs nondependent
– morphine type – 305.50
• Person feigning illness (Malingerer)
– V65.2
Example 2 ICD-10-CM Answer
• L03.221 Cellulitis (diffuse) (phlegmonous)
(septic) (suppurative), neck (region)
• F11.10 Abuse, drug, morphine type
(opioids)
• Z72.89 Behavior, drug seeking
Skin Example 3
• Pt w/ gangrenous pressure ulcer of R hip
w/cellulitis & pressure ulcer of sacrum
documented by physician.
• Nursing assessment indicates stage 2
pressure ulcer of the sacrum w/stage 3
decubitus ulcer of R hip.
•
Skin Example 3 ICD-9-CM
Answer
• Ulcer, Pressure
– Hip
707.04
– Stage III707.23
– Sacrum 707.03
– Stage II 708.22
• Cellulitis
– Specified site NEC 682.8
• Ulcer codes do NOT include cellulitis
Example 3 ICD-10-CM Answer
• I96 Ulcer, gangrenous • L89.152 Ulcer, … stage 2,
… partial thickness skin
• L89.213 Ulcer, …
loss involving epidermis
ulceration, ulcerative,
and/or dermis) sacral
pressure (pressure
region (tailbone)
area) stage 3,
(healing) (full
thickness skin loss
• L03.115 Cellulitis (diffuse)
involving damage or
(phlegmonous) (septic)
necrosis of
(suppurative), hip
subcutaneous tissue),
hip
Example 3 Explanation
• Decubitus ulcers classified to pressure ulcers
• L89 NOTE indicates sequencing
– Any associated gangrene listed 1st
• L89.2 classifies pressure ulcers of hip
– Review Tabular to select correct stage & laterality
– Id code L89.213 = stage 3 of right hip
– Excludes2 note at beginning of category L89
includes “skin infections L00-L08.”
– Therefore Hip cellulitis = additional Dx
Example 3 Explanation
• Pressure ulcer of sacral region documented
stage 2
– L89.152 assigned
– Sacral region includes tailbone & coccyx - Coding
Guideline
• Coding Guideline I.B.14
– Stage of pressure ulcer may be documented by
another healthcare clinician & coded as long as
pressure ulcer documented by provider
Skin Example 4
• Atherosclerosis of R ankle (native artery),
w. non-healing ulcer, w/ breakdown of skin
Example 4 ICD-9-CM Answer
• Atherosclerosis
– See Ateriosclerosis
• With Ulceration – 440.23
• Use add’l code for ulcer
• Ulcer, lower extremity, ankle – 707.13
• 440.23
• 707.13
Example 4 ICD-10-CM Answer
• I70.233 Atherosclerosis … (diffuse)
(obliterans) (of) (senile) (with calcification),
extremities (native arteries) leg, right, with
ulceration (and intermittent claudication &
rest pain), ankle
• L97.311 Ulcer, … ulcerative, lower limb
(atrophic) (chronic) (neurogenic)
(perforating) (pyogenic) (trophic) (tropical)
ankle, right, with skin breakdown only
Example 4 Explanation
• NB: In Index under arteriosclerosis
– Bypass graft codes of extremities listed 1st
• MUST scan until reaching Leg –left/right, etc.
• I70.23 – Note: Use add’l code to identify
severity of ulcer (L97.- w/ 5th char
• L97 - Note: Code 1st any associated
underlying condition
Example 4 Explanation
• L97 code may be used as PrDx/First listed
code IF no underlying condition documented
• IF one of underlying conditions listed here
• is documented w/ lower extremity ulcer
– Causal condition should be assumed
– atherosclerosis of lower extremities
– chronic venous hypertension
– diabetic ulcers, postphlebitic syndrome, varicose
ulcer
• Codes must be listed in this order
Skin Example 5
• 35-y-o male presents w/ edema, redness,
& pain of L big toe. He didn’t seek tx
because thought it would improve. He
doesn’t remember an injury, but pain has
been progressively worse for past week
• Diagnosis: Gangrenous abscess of entire
L big toe.
Example 5 ICD-9-CM Answer
• Abscess, toe
– 681Cellulitis and abscess of finger and toe,
681.1 Toe
– 681.10 Cellulitis and abscess, unspecified
• Gangrene 785.4
– Code 1st any associated underlying condition
• 681.10
• 785.4
Example 5 ICD-10-CM Answer
• L02.612 Abscess (connective tissue)
(embolic) (fistulous) (infective) (metastatic)
• (multiple) (pernicious) (pyogenic) (septic),
toe (any) see also Abscess, foot.
• I96 Gangrene, gangrenous (connective
tissue) (dropsical) (dry) (moist) (skin)
• (ulcer) (see also necrosis).
Example 5 Explanation
• Individual categories for abscess (L02) &
cellulitis (L03)
– In ICD-9-CM, these are combined
• Note: In Index
– Abscess of toe classifies to abscess of foot
– Abscess of toenail classifies to cellulitis, toe
• No Includes/Excludes notes
– Stop use of abscess & gangrene code together
• No sequencing guideline available
Skin Example 6
• Elderly patient seen for tx of
cellulitis in R LE. Cultures grew
streptococcus B; documented by
physician as etiology of cellulitis.
Patient also has stage 1
decubitus ulcer of L buttock &
stage 2 decubitus ulcer in R
gluteal region
Example 6 ICD-9-CM Answer
• Cellulitis, leg
– 682.6
– 041.02
• Use add’l code to id organism, such as Staphylococcus
(Note at 682)
– 705.05
– 707.21
– 707.22
• Per Faye Brown - Same site, different stages: Assign
one code for site & separate codes for each stage
Example 6 ICD-10-CM Answer
• L03.115 Cellulitis, lower limb
• B95.1 Infection, bacterial NOS, as cause of
disease classified elsewhere, Strep group B
• L89.312 Ulcer, pressure, by site. Pressure
(pressure area) stage 2, … buttock
• L89.321 Ulcer, pressure, by site. Pressure
(pressure area) stage 1, (healing) (pre-ulcer
skin changes limited to persistent focal
edema), buttock
Skin Example 6 Explanation
• Documentation supports cellulitis as 1st dx
• ICD-10-CM classifies laterality of cellulitis of
LE w/ L03.115 = RLE
• Note in Tabular at (L00-L08)
– Use add’l code (B95-B97) to id infectious agent
• ICD-10-CM also classifies decubitus ulcers of
buttocks stage AND laterality
– Gluteus not in classification, but refers to buttock
• Coder must apply A&P knowledge
Skin Example 7
• Pt seen for tx of fine rash developing on pt’s
trunk & UEs over last 3-4 days. Pt dxed w/
HTN 7 days ago & on Ramipril 10 mg daily.
Physician determined cause of rash as
dermatitis due to Ramipril; discontinued & Pt
prescribed new anti-HTN
medication, Captopril.
Also, physician prescribed
topical cream for
localized dermatitis.
Example 7 ICD-9-CM Answer
• Rash
– Drug (internal use) – 693.0
– Use additional E code to identify drug (693.0 note)
– E942.6
– 401.9
• Ramipril = Alcace (ACE inhibitor)
– In Table - antihypertensive agents NEC
Example 7 ICD-10-CM Answer
• L27.1 Dermatitis, (eczematous) due to
drugs and medicaments, (generalized)
(internal use) localized skin eruption
• T46.4X5A Table of Drugs and Chemicals,
Ramipril, Adverse Effect, initial encounter
• I10 Hypertension, hypertensive
(accelerated) (benign) (essential)
(idiopathic) (malignant) (systemic)
Skin Example 7 Explanation
• Reason, after study, for encounter is
dermatitis; adverse effect of Ramipril
• Instructional note in Tabular at L27.1
– Use add’al code for adverse effect, if applicable, to
id drug (T36-T50 with 5th/6th character 5)
• T46.4X5A sequenced as 2ndary dx
– 7th character of A indicates initial encounter for
condition
– Documentation = localized dermatitis
– Documentation doesn’t = long-term use of drug
Skin Example 8
• Pt seen w/extensive inflammation &
irritation of skin of upper eyelids & under
eyebrows; spreading to temples &
forehead. During H&P, she stated
recently used new eye cosmetics. Pt
seen during prior visit for cystic acne.
Skin Example 8
• Physician also examined pt’s cystic acne
on forehead & jawline. Pt advised to use
medication previously prescribed.
• Dx = irritant contact dermatitis due to
cosmetics & cystic acne.
• Pt was advised to immediately discontinue
use of any make-up on face & given
topical medication to resolve inflammation.
Example 8 ICD-9-CM Answer
• Dermatitis
– Due to cosmetics - 692.81
• 692 = contact dermatitis
• Acne, cystic
– 706.1
Example 8 ICD-10-CM Answer
• L24.3 Dermatitis (eczematous), contact, irritant,
due to, cosmetics
• H01.114 Dermatitis (eczematous), eyelid,
contact – left, upper
• H01.111 Dermatitis (eczematous), eyelid,
contact – right, upper
• T49.8X5A Table of Drugs and Chemicals,
Cosmetics, adverse effect
• L70.0 Acne, cystic
Skin Example 8 Explanation
• Reason for encounter was contact dermatitis
due to adverse reaction to use of new eye
cosmetics
• 7th character A = initial encounter for
condition.
• Several different Index terms for dermatitis.
Skin Example 8 Explanation
• Irritant contact dermatitis, but not allergic
– Index = Contact, irritant, due to cosmetics,
L24.3.
– Contact, allergic, due to cosmetics = L23.2
– Contact dermatitis (not documented as
irritant) due to cosmetics is coded L25.0
• Careful review of record and Index
required
Skin Example 8 Explanation
• In addition, reference to specific site (upper
eyelids) – has separate classification
• L24,
– Excludes2 note for dermatitis of eyelid (H01.1-)
– IF both conditions present, both codes may be
assigned
• Cystic acne assigned as 2ndary condition
– Also E&M during encounter
Dermal Appendages
Office Visit Example
• 54-y-o female presents w/ infected cuticle on left
thumbnail. Pt states started about one week ago.
She denies any discharge from nail but throbbing
pain at night. She is a bartender, hands frequently in
water. Denies any trauma to hand. No possibility of
fracture. No nausea, vomiting or diarrhea, fever or
chills.
• Pt has cough. She has smoked pack/day for past
20+ years. Cough is typical and sometimes
productive of whitish clear sputum.
Office Visit Example
• Allergies: Penicillin & iodine both which produce hives.
• Social Hx: Drinks 2 beers/day. No illicit drug use.
• ROS: Pt never had chest x-ray. Up to date on Pap smears
and mammogram.
• PE: Blood pressure is 118/66. Pulse 70. Respiration 12.
Temp is 98.5. Lungs are clear to auscultation. No rales,
rhonchi, or wheezing. Heart is RRR. Abdomen is soft,
nontender, and nondistended. To the lateral aspect of the
left thumbnail bed there is increased swelling and erythema
with no discharge noted. There is exquisite tenderness on
palpation.
Office Visit Example
• Impression:
– 1. Paronychia left thumbnail - levaquin 750
mg once a day for five days
– 2. Smokers’ cough - chest x-ray ordered,
CMP, lipids, TSH and CBC ordered.
– 3. Tobacco abuse
ICD-9-CM Answer
• Paronychia, finger
– 681.02 Onychia and paronychia of finger
• Cough, Smokers’
– 491.0 Simple chronic bronchitis
• Tobacco abuse
– 305.1 Tobacco use disorder
ICD-10-CM Answer
• Paronychia – see also Cellulitis, digit
• L03.012 Cellulitis (diffuse) (phlegmonous)
(septic) (suppurative), digit, finger – see
Cellulitis, finger (intrathecal) (periosteal)
(subcutaneous) (subcuticular)
• J41.0 Cough (affected) (chronic)
(epidemic) (nervous), smokers’
• Z72.0 Tobacco (nicotine), use
ICD-10-CM Explanation
• Cellulitis of finger (Thumb NOT specified) is
L03.01- with a sixth digit of 2 for left finger.
• The Index does NOT provide entry for
tobacco or nicotine under Abuse Main Term,
but category J41.0 does direct coder to use
add’l code to id tobacco use, Z72.0.
Pressure ulcer Case
• A 73 year old male is followed
in your clinic Diagnoses
– Type II Diabetes Mellitus
– Hypertension
– Hyperlipidemia
– CVA 18 mos ago
– Obesity
– 54-pack-year smoking
history (quit 2 years ago)
– Diabetic neuropathy
– Diabetic retinopathy
– Diabetic gastroparesis
• Medications
– 70/30 insulin bid
– Lisinopril
– Simvastation
– Enteric coated aspirin
– Metoclopramide ac and
hs
PU Case
• After stroke 18 months ago, dx w/ depression, tx
for 6 months with sertraline, with improvement of
mood to normal. Drug discontinued.
• Most recent functional assessment by visiting
RN was that pt needed assistance w/bathing,
otherwise independent. HH aide provided
assistance w/ bathing & light housework,
daughter visited almost every day.
PU Case
• Pt brought into ED by ambulance, after his
daughter found him at home lying on floor,
unconscious. ED room physician admits him w/
Dx of pneumonia, fall with long lie, dehydration,
and altered mental status.
• By 2nd hospital day, he developed new pressure
ulcer over right lateral malleolus.
• Examination of ulcer shows a round, 3 cm black
eschar that is debrided to an ulcer that extends
through dermis.
ICD-9-CM Codes
ICD-10-CM Codes
Break Time
Injury and Poisoning
Injury and Poisoning
• ICD-9-CM – Chapter 17
– Organized by TYPE of Injury, then body part
• ICD-10-CM – Chapter 19
– Organized by BODY REGION, then specific types
of injuries
• Starting head & ending with ankle and foot
– Also blocks for
• Effects of foreign body
• Burns
• Frostbites, Poisoning, Adverse effects and Other
consequences of external causes.
Injury and Poisoning Chapter
• ICD-10-CM Chapter 19 – 2 sections
–S =
• Various types of injuries related to single body
regions
–T =
• Injuries to unspecified body regions
• Poisonings & certain other consequences of
external causes
• 7th Character Extension required for many
chapter codes
ICD-10-CM Chapter 19
• More details
• Laterality & type of encounter (initial,
subsequent, sequela)
– Significant component of code expansion
• 7th character = type of encounter
Initial Encounters (A)
• Initial encounter 7th character used while
patient receiving active treatment for
condition
– Surgical treatment
– Emergency department encounter
– Evaluation and treatment by new physician
• Can be used each time pt actively treated
for same condition
Subsequent Encounter (D)
• Subsequent encounter 7th Character used for
encounters after patient received active tx for
condition
• Now receiving routine care for condition
during healing or recovery phase
– Cast change or removal
– Removal of external or internal fixation device
– Medication adjustment
– Other aftercare & follow-up visits following
treatment of injury or condition
Sequela Encounter (S)
• Sequela 7th character used for complications or
conditions directly due to condition, such as
scar formation after burn (Scar is sequela).
• MUST use both injury code that caused
sequela AND code for sequela itself
• S added ONLY to injury code (burn), NOT
• sequela code (scar)
• Type of sequela (e.g., scar) sequenced 1st,
then injury code
Aftercare Codes
• Aftercare Z codes NOT used for aftercare
for conditions when 7th seventh characters
available to id subsequent episodes of care
• For aftercare of injury, assign acute injury
code with 7th character for “subsequent
encounter.”
Adverse Effects and Poisonings
(T36-T50)
• Adverse Effects
– Nature of adverse effect first
– Followed by code for drug
• Poisonings
– Poisoning Code
– Code(s) for all manifestations
– Followed by code for drug
• Same sequencing as ICD-9-CM
T36-T50
• Includes:
– Adverse effect of correct substance properly
administered (hypersensitivity, reaction, etc.)
– Poisoning by
• Overdose of substance
• Wrong substance given or taken in error
– Underdosing by (NOT in ICD-9-CM)
• (inadvertently) (deliberately) taking less substance than
prescribed or instructed
• Use add’l code for INTENT OF underdosing
– Failure to dose during medical/surgical care
– Pt’s underdosing
Multiple Injuries
• Code for most severe injury is sequenced
as Principal Diagnosis
– Determined by physician
– Treatment provided
Sequencing Multiple Injuries
• Injury attending
physician ids as
most resourceintensive is PDX.
• General
sequencing
guidelines from
Rules of
Certification and
Medical
Classification of
ICD-9 are
• A. Fx of skull & cervical vertebrae
• B. Internal injury of chest,
abdomen, & pelvis
• C. Fx of face bones, spine, & trunk
• D. Other head injury
Open wounds of neck & chest
Traumatic amputation of limbs
Spinal cord lesion w/ mention of
vertebrae fx
• E. Fx of limbs
• F. Burn
• G. Other injuries not listed above
Burns ICD-9-CM
• Burns classified by
– Depth
– Extent
– Agent (E code)
• Review documentation for
– Location/anatomic site of burn
– Extent/severity of burn
– Percentage of body surface burnt
– Cause of burn
Burns ICD-10-CM
• Guidelines are same for burns & corrosions
• Current burns (T20–T25) are classified by
– Depth (1st, 2nd, 3rd)
– Extent (TBA)
– Agent (X code). (E code in ICD-9-CM)
• Burns of eye & internal organs (T26–T28) classified
by site, NOT degree
• Add’l Code for infected burn
• Separate codes for each burn site
• T30, Burn & corrosion, body region unspecified extremely vague -use rarely
Rule of Nines
• ADULT:
I. Head and Neck
=
II. Posterior Trunk
=
III. Anterior Trunk
=
IV. Each Upper Extremity =
V. Each Lower Extremity =
VI. Perineum
=
9%
18%
18%
9%
9%
1%
Rule of Nines
• BABY:
I.
II.
III.
IV.
V.
Head and Neck
=
Posterior Trunk
=
Anterior Trunk
=
Each Upper Extremity =
Each Lower Extremity =
18%
18%
18%
9%
14%
http://www.idrawdigital.com/wp-content/uploads/2009/01/prop2.jpg
Multiple Burns Sequencing
• PDX is burn site of greatest severity
– Then use following order
• A. Deep necrosis of underlying tissues w/
loss of body part (deep 3rd/4th degree)
B. Deep necrosis of underlying tissues without
loss of body part (deep 3rd/4th degree)
• C. Full-thickness skin loss (3rd degree)
• D. Blisters, epidermal loss (2nd degree)
• E. Eythema (1st degree)
• F. Unspecified
ER Burn Example
• Pt seen in ER today for burn of right
ankle.
• Pt was cooking dinner in kitchen of
her single family home & carrying
pot of boiling hot liquid that
splashed on her ankle.
• Physician states DX as:
• 2nd degree burn, right ankle.
ER Burn Example
ICD-9-CM Answer
•
•
•
•
945.23 Burn, Ankle, 2nd Degree
E924.0 Accident Due to Hot Liquid/Vapor
E849.0 Accident Occurring in Home
E015.0 Activities Involving Food
Preparation And Clean Up
• E000.8 Leisure Activity
ICD-10-CM Answer
• T25.211A Burn (electricity) (flame) (hot gas, liquid or
hot object) (radiation) (steam) (thermal), ankle, right,
second degree
• X12.XXXA Index to External Causes, Burn, burned,
burning (accidental) (by) (from) (on), hot liquid
• Y92.010 Index to External Causes, Place of
occurrence, residence (noninstitutional) (private),
house, single family, kitchen
• Y93.G3 Index to External Causes, Activity (involving)
(of victim at time of event), cooking and baking
• Y99.8 Index to External Causes, External cause
status, leisure activity
ICD-10-CM Explanation
• Documentation states that patient was
cooking dinner at home.
– External cause status for this is leisure.
• Burn code and external cause code are
coded with 7th character A
– Initial encounter because pt seen in ED today
Wounds ICD-9-CM
• 4th-digit subcategory may id wound is
complicated
• Complicated open wound includes
mention of
– Delayed healing
– Delayed treatment
– FB retention
– Infection
Delayed Healing
• Delayed treatment & healing tends to lead to
infections, which = complicated open wound
• NO strict definition of delayed healing or tx
• Ex: If pt delays seeking treatment by one week, &
wound does not appear to be healing appropriately,
then use complicated code
• If coder NOT sure, query physician
Open Wounds
• Coding directive before category 860
– Description ‘with open wound,’ used in 4thdigit subdivisions, includes those w/ mention
of infection or foreign body.
• Do NOT code Superficial injuries
(abrasions, contusions, etc.) when
associated with more severe injuries of
same site.
Cellulitis Vs Open Wound
Sequencing depends on circumstances of admission/encounter
• Pt suffered laceration of
lower leg while hiking 2
days ago; came to hospital
on his return.
– Cellulitis beginning to
develop. Wound
cleansed, nonexcisional
debridement, &
antibiotics started for
cellulitis.
• 891.1, 682.6 Cellulitis
• Pt suffered minor puncture
injury to finger removing
staple at office. 5 days later,
admitted to hospital because
of cellulitis of finger, tx with
IV.
• Wound didn’t require tx,
therefore not coded
• 681.00 Cellulitis
Wounds ICD-10-CM
• Injuries are classified by Body SITE, then type
• Open wounds consistent across body sites
• Types of open wounds classified in ICD-10-CM
– Laceration without foreign body
– Laceration with foreign body
– Puncture wound without foreign body
– Puncture wound with foreign body
– Open bite
– Unspecified open wound
Wounds in ICD-10-CM
• Note: Code also any associated wound
infection
• NO concept of delayed healing/treatment
• Some types may have add’l and/or unique
code specificity
– w/ or w/o penetration into body cavity or organ
– Add’l specificity of laceration as minor, moderate,
or major
– Add’l anatomic specification
• left/right, front/back, flexor/extensor
Wound Example
• 2 cm laceration of left heel with foreign
body
• ICD-9-CM
– Laceration – see also Wound, open, by site
– 892.1 Open wound of foot except toe(s)
alone, Complication
Wound Example
ICD-10-CM Answer
• S91.322A Laceration, heel – see Laceration,
foot (except toe(s) alone), left, with foreign
body. Review Tabular for correct 7th
character
• Explanation:
• ICD-10-CM Index ids both laterality &
presence of FB with laceration code
• 7th character A indicates initial encounter
Poisonings in ICD-10-CM
• Combination codes for poisonings &
associated external cause (accidental,
intentional self-harm, assault, undetermined)
• Rearranged Table of Drugs & Chemicals
– All poisoning columns together, then adverse
effect and underdosing
• When intent is NOT documented, code
Accidental
• Undetermined intent = specific documentation
in record; intent of toxic effect can’t be
determined
Poisoning Example
• Woman admitted for intentional overdose
of marijuana & cocaine. She sustained fall,
resulting in left cheek & scalp laceration.
• After she stabilizes medically, she will be
transferred to a psychiatric unit.
Poisoning Example
ICD-9-CM Answer
• 969.6 Poisoning by Psychodysleptic
[Hallucinogen]
• E950.3 Self-Inflicted Poison w
Tranquilizer/Psychotropic
• 970.81Poisoning by Cocaine
• Self-Inflicted Poison w Drug/Medicine NEC
• 873.41 Wound, open, Cheek
• 873.0 Wound, open, scalp
• E888.9 Fall, unspecified
Poisoning Example
ICD-10-CM Answer
• T40.7X2A Table of Drugs and Chemicals,
Marijuana, Poisoning, Intentional, Self-harm. Review
Tabular for 7th character.
• T40.5X2A Table of Drugs and Chemicals, Cocaine,
Poisoning, Intentional, Self-harm.
• S01.412A Laceration, cheek (external).
• S01.01XA Laceration, scalp.
• W19.XXXA Unspecified fall, initial encounter
Poisoning Example
ICD-10-CM Explanation
• If overdose of drug intentionally taken or
administered and resulted in drug toxicity,
coded as poisoning.
• 7th character is required for all codes in
this Example.
Skin Procedural Coding
• CPT
– Outpatient
– Physician
Skin (Integumentary)
• Adjacent Tissue Transfer/Rearrangement –
defined by anatomic site & defect size
– Includes excision of defect or lesion
• Do NOT code separately
– NOT used when traumatic wounds incidentally
result in configurations such as Z-plasty, etc.
– Describe moving normal tissue from donor site to
recipient site
• Donor site adjacent (next to) recipient site, therefore
donor tissue remains attached to its original blood
supply.
Biopsy Services
• Removal of small amount of tissue to
determine extent of disease or to determine or
confirm dx
– Include: needle aspiration, incisional bx, partial
excision, scraping, curetting, skin punch
• Use integumentary codes when bx of skin and
SQ tissue ONLY
• Incisional Bx code = tissue SAMPLED
• Excision code used when ALL suspect tissue
removed
Burn Treatment
• Local (16000-16036)
– Application of materials is included
– Review MR to Id
• % of body surface (Rule of Nines)
• Severity of burn
– Partial- thickness (1st-2nd degree)
– Full-thickness (3rd degree)
Destruction of Lesions
• Ablation of
– B9
– Premalignant or
– Malignant tissue
• Destruction includes
local anesthesia
• NO tissue left for
• By any combination of
pathology =
– Electrosurgery
Destruction
– Cryosurgery
• IF there is pathology
– Laser
report, was NOT
– Chemical tx
destruction
Diagnostic VS Therapeutic
Services
• Dx Services – Determine or establish pt’s dx
Help establish nature of pt’s disease or
condition for future, definitive care
– Follow-up care for dx procedures includes ONLY
care directly related to dx procedure
– Care of condition identified by dx procedure is
NOT included; may be listed separately
• Tx Services – Treat specific, known
condition
– Include procedure, various incidental incidents,
and normal, related follow-up care
Excision of Lesions
• Full-thickness removal of lesion & INCLUDES
simple closure
– Add’l code needed for intermediate (layered) or
complex closures (see wound repair)
• Coder must determine
– type of lesion (B9/malignant)
– anatomic site
– lesion diameter
Types of Lesions
• B9 –
– Cicatricial, fibrous, inflammatory,
congenital, cystic, noninvasive
• Malignant
– Invasive, potential to metastasize, BCC
and melanomas
Flaps and Grafts
• Involve moving normal tissue from one site
to another
• Donor site = where tissue originates
• Recipient site = where it is relocated
•
• Surgical preparation of recipient site is
reported separately
Flaps
• Flaps of skin and deep tissues
– Defined by graft type (direct, tube, delayed,
intermediate, muscle, myocutaneous, fasciocutaneous) AND site
• Site listed in code description
– Recipient site when flap attached to final site
– IF flap formed for DELAYED transfer, site refers to
donor site
• Any extensive immobilization
– Add’l procedure coded separately
• Repair of donor site with skin grafts/local flaps
reported separately
Free skin grafts
• Defined by size, location of recipient site
(defect area), and type of graft
• Reported separately when done in
conjunction with other procedures
– Mastectomy , etc.
Laser Surgery
• Usually included in “destruction by any
method.”
• IF using laser significantly alters procedure
performance, use codes that specifically
identify laser in their descriptions
Wound Repair
• Surgical closure of wound; may be caused by
injury/ trauma OR surgically created defect
• 3 categories of wounds –
– simple, intermediate, complex,
– described by anatomic site, then size
• Adhesive strips ONLY = E/M code ONLY
Wound Repair Categories
• Simple – superficial wound (partial/full-thickness
damage to skin/SQ). ONE layer suturing
– Includes local anesthetic, chemical or electrocauterization of
non-closed wounds
• Intermediate – one or more of deeper skin tissue
layers & non-muscle fascia repaired
– May be single-layer closure IF wound heavily contaminated
& requires extensive cleaning
• Complex – more than layered closure
– Needing revision, debridement, undermining, placement of
stents/retention sutures
– Needing creation of defect (extending excision), and special
preparation of site
Wound Repair Rules
• Measure length of wounds & report in cms
• Add together lengths of multiple wounds in SAME
classification (same category AND same anatomic
grouping) and report ONCE
• Wounds in more than one classification
– Listed separately w/ more complicated procedure listed 1st
• Decontamination/debridement integral to repair
EXCEPT when gross contamination requires
– Prolonged cleaning
– Removal of appreciable amounts of devitalized/
contaminated tissue
Wound Repair Rules, cont.
• Repair of nerves, blood vessels, & tendons reported
using appropriate section codes
• Repair of associated skin wounds is considered
INTEGRAL to repair & NOT reported unless
COMPLEX skin repair
– add -51 to complex skin repair code
• Simple exploration of nerves, vessels, & tendons
exposed in wound part of repair
• Wounds requiring exploration, enlargement,
extension, dissection, removal of FB, &/or
ligation/coagulation of minor blood vessels reported
with 20100-20103
CPT Wound Example 1
• Foot and ankle surgeon performs
débridement to muscle of 6 sq cm open
wound on lateral posterior calf and
selective débridement of skin in 3 sq cm
wound on medial posterior calf.
11043—Débridement, muscle and/or fascia (includes epidermis,
dermis, and subcutaneous tissue, if performed); 1st 20 sq cm or
less
97597—Débridement (eg, high pressure waterjet with/w/out
suction, sharp selective débridement w/ scissors, scalpel &
forceps), open wound, (eg, fibrin, devitalized epidermis and/or
dermis, exudate, debris, biofilm), incl. topical application(s),
wound assessment, use of whirlpool, when performed and
instruction(s) for ongoing care, per session, total wound(s) surface
area; first 20 sq cm or less
Use -59 indicates selective débridement of separate wound.
http://www.aaos.org/news/aaosnow/jul11/managing1_f3.pdf
CPT Wound Example 2
• a patient has a contaminated laceration on
the foot. When the patient was first seen,
the orthopaedic surgeon débrided the
laceration. Several days later, the patient
was taken to the operating room and the
surgeon performed a surface area
débridement to prepare the wound for a
complex closure. The patient was not in a
global period.
13121—Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm
13122—Repair, complex, scalp, arms, and/or legs; each additional 5 cm
or less (List separately in addition to code for primary procedure)
15004-51—Surgical preparation or creation of recipient site by excision of
open wounds, burn eschar, or scar (including subcutaneous tissues), or
incisional release of scar contracture, face, scalp, eyelids, mouth, neck,
ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or
1 percent of body area of infants and children
Alternative coding format reports units for add-on code, 13122
This format should be used only if payer requires
When all units are reported on one line, fees should reflect
number of units.
Because single line for code 13122 reflects 3 units, fees are
tripled.
*Some payers may require use of - 59 on 2nd-5th add-on code,
while others may require add-on code reported in units
CPT Wound Example 3
• Foot & ankle surgeon sees elderly F pt
with open ulcerated area on left lower leg
and separate lesion on right lower leg. The
surgeon documents excision of skin,
subcutaneous tissue, & muscle (4.0 cm ×
3.0 cm, or 12 sq cm) in right lower leg and
excision of skin and subcutaneous tissue
in left lower leg (3.0 cm × 8.0 cm, or 24 sq
cm).
Wound Coding Answer
• Document needed
– Anatomic location
– Depth of débridement
– Surface area of wound(s)
• Report each wound separately because
depths of débridement not the same
• Use -59 with both distinct second
procedure and associated add-on code
Reported Codes
11043—Débridement, muscle and/or fascia (includes epidermis,
dermis, and subcutaneous tissue, if performed); first 20 sq cm or less
(Right lower leg)
11042-59—Débridement, subcutaneous tissue (includes epidermis
and dermis, if performed); first 20 sq cm or less (Left lower leg)
11045-59—Each add’l 20 sq cm, or part thereof (List separately in
addition to code for primary procedure) (Left lower leg)
CPT
Same-Day Surgery Example
• 55-y-o female pt who had a lesion removal
2 weeks ago, returns now for wide
excision of a malignant melanoma on right
calf. Excision consists of 3-cm diameter
area. Layer closure is required. The
Pathology report shows clear margins.
Answer
• 172.7
• 11603
• 12032
OR C43.71 (ICD-10-CM)
Questions from previous
Sessions
• CMS confirmed that code freeze will hold
until ICD-10-CM/PCS implemented
regardless of delay
General Resources
• Comparison of ICD-9-CM & ICD-10-CM Chapters 2010
– http://hhic.org/_library/documents/audioconferences/icd10/icd-10-cm_chaptersx-walkissue.pdf.pdf
• Faye Brown Coding Handbook. 2012 Rev. Ed.
• Green, M. 3-2-1 Code It! 3rd ed. 2012. Delmar.
• ICD-9-CM Coordination and Maintenance Committee
Meeting December 6, 2002
– http://www.cdc.gov/nchs/data/icd9/agendadec02.pdf
General Resources
• ICD-9-CM Official Guidelines for Coding and Reporting,
Effective October 1, 2011.
– http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.
pdf
• Endicott, M. E. et. al. Clinical Coding Workout: Practice
Exercises for Skill Development; With Answers. 2012.
AHIMA.
• Endicott, M. New ICD-9-CM Diagnosis Codes for FY
2012.
– http://library.ahima.org/xpedio/groups/public/documents/ahi
ma/bok1_049234.hcsp?dDocName=bok1_049234
• Resource Library. SelectData. (Home Health and Hospice)
– http://www.selectdata.com/what-you-care-about
Burn Coding Resources
• Coding for Burns. ICD-9-CM Medical Coding
Exercises.
– http://wps.prenhall.com/chet_vines_medicalbilling_1/86/22
079/5652224.cw/-/5652340/index.html
• Understanding Burn Codes Just Made Easy.
– http://www.symbiosisbilling.com/blog/bid/55034/Understan
ding-Burn-Codes-Just-Made-Easy
• ICD-9 coding for burns. Quiz. Just coding. HCPro.
– http://justcoding.com/quiz/553
• Understanding Burn Codes. PPT Slides.
– http://www.mlcoleman.com/review/coding_burns_part1.pdf
Skin Coding Resources
• 2012 Major Coding Changes to Skin Replacement and
Skin Substitute CPT Codes.
– http://ameriburn.org/2012MajorCodingChanges.pdf
• Address medical necessity, coding challenges related
to wound care. JustCoding News: Inpatient, 6/20/2012
– http://www.hcpro.com/HIM-281425-3288/Address-medicalnecessity-coding-challenges-related-to-wound-care.html
• Budny, A. M., Budny, J. M. Diabetic Wound Healing Experience
in the Rural Health Care Setting (Cases with Pictures). The
Journal of Diabetic Foot Complications, Vol 1, Issue 3, No. 1.
– http://jdfceditors.files.wordpress.com/2009/09/diabetic_wound_healing_e
xperience.pdf
Skin Coding Resources
• Coding compliance: Open Wound as a primary
diagnosis. Video. 2.39 minutes. Home Care Coding.
– http://www.selectdata.com/coding-compliance-openwound-as-a-primary-diagnosis-2
• Grider, D. Walk Through Skin and Subcutaneous
Tissue Crossovers. AAPC Coding Edge.
– http://aapcperfect.s3.amazonaws.com/ppdf/ICD-10-March20091.pdf
• Howard, A. Coding for Open Wounds. For The
Record, Vol. 24 No. 7 P. 28. 4/9/2012
– http://www.fortherecordmag.com/archives/040912p28.shtml
Skin Coding Resources
• Jones, L. Skin Ulcer Coding in ICD-10-CM. ICD10
Monitor. 2/2012
– http://www.icd10monitor.com/index.php?option=com_conte
nt&view=article&id=317:skin-ulcer-coding-in-icd-10cm&catid=68:asc&Itemid=116
• LeGrand, M. Changes in reporting wound
débridement—2. July 2011. AAOS.
– http://www.aaos.org/news/aaosnow/jul11/managing1.asp
• Q&A: Coding for dry skin due to cold weather. HIM
Connection, May 29, 2012
– http://www.hcpro.com/HIM-280526-865/QA-Coding-for-dryskin-due-to-cold-weather.html
Skin Coding Resources
• Skin biopsies. Coding for physician work associated with skin
biopsies (e.g. CPT codes 11100 or 11101). AAD.
– http://www.aad.org/member-tools-and-benefits/practice-managementresources/coding-and-reimbursement/skin-biopsies
• Update on 2012 CPT codes for wound care. Wound Healing
Society.
– http://www.woundheal.org/news-you-can-use
• Verhovshek, G. J. 3 Rules to Correct Benign and Malignant
Skin Lesion Excision Coding. SurgiStrategies. 3/5/2012.
– http://www.surgistrategies.com/articles/2012/03/3-rules-tocorrect-lesion-excision-coding.aspx
• Zeisset, A. "Coding Injuries in ICD-10-CM." Journal of AHIMA
82, no.1 (January 2011): 52-54.
– http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_04
8533.hcsp?dDocName=bok1_048533
CPT Coding Resources
• CPT Coding Questions - Skin and Integumentary.
– http://medical-coding-carers.blogspot.com/2009/12/cptcoding-questions-skin-and.html
• Janevicius, R. Multiple new CPT codes appear in
2012. 1/19/2012.
– http://psnextra.org/Columns/CPT-CornerJanuaryFebruary-2012.html
[email protected]